Claims-based Reporting Mechanism

2016 Physician Quality

Reporting System (PQRS):

Implementation Guide

Table of Contents

Introduction............................................................................................................................... 3

PQRS Measure Selection Considerations...................................................................................... 6

Satisfactorily Report Measures....................................................................................................11

Appendix A: Glossary of Terms...................................................................................................12

Appendix B: Decision Trees - 2016 PQRS Reporting/Participation for Avoiding the 2018 Negative

Payment Adjustment ...............................................................................................19

Appendix C: PQRS Claims-Based Process (Data Flow)..................................................................29

Appendix D: CMS-1500 Claim PQRS Example..............................................................................30

Appendix E: CMS-1450 Claim PQRS Example..............................................................................32

Appendix F: EHR Process (Data Flow).........................................................................................35

Appendix G: Registry Process (Data Flow) ...................................................................................36

Appendix H: PQRS GPRO Web Interface Process (Data Flow)........................................................37

Appendix I: QCDR Process (Data Flow) .......................................................................................38

Appendix J: Revision Notes........................................................................................................39

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 2 of 39

Introduction

Purpose
The “2016 PQRS Implementation Guide” helps individual eligible professionals (EPs) and group practices
participating in PQRS via the group practice reporting option (GPRO) (referred to as PQRS group
practices) understand and report for 2016 PQRS. It addresses common PQRS implementation concerns,
such as:
 Program questions: What is PQRS? Why should I participate?
 Measures and Analysis questions: How do I select which measures to report? How does my
data get analyzed?
 Reporting questions: What are the different ways I can report? When do I need to report and
how do I report?
To supplement this guide, EPs may get the latest information about PQRS on the PQRS website, via the
PQRS listserv and also on Twitter. Help Desk support is also available Monday – Friday from 7:00 AM­
7:00 PM Central Time at 1-866-288-8912 (TTY: 1-877-715-6222) or at [email protected].
What is PQRS?
PQRS is a quality reporting program that uses negative payment adjustments to promote reporting of
quality information by individual EPs and group practices. Those who do not satisfactorily report data on
quality measures for covered Medicare Physician Fee Schedule (MPFS) services furnished to Medicare
Part B beneficiaries (including Railroad Retirement Board, Medicare Secondary Payer, and Critical
Access Hospitals [CAH] Method II) will be subject to a negative payment adjustment under PQRS.
Medicare Part C–Medicare Advantage beneficiaries are not included. Reporters may choose from the
following reporting mechanisms to submit their quality data:
 Reporting electronically using an electronic health record (EHR)
 Qualified Registry
 Qualified Clinical Data Registry (QCDR)
 PQRS group practice via GPRO Web Interface
 CMS-Certified Survey Vendor
 Claims
All EPs who do not meet the criteria for satisfactory reporting or participating for 2016 PQRS will
be subject to the 2018 negative payment adjustment with no exceptions.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 3 of 39

Who is eligible to participate in PQRS?
Medicare physicians, practitioners, and therapists providing covered professional services paid under or
based on the MPFS are considered EPs under PQRS. To the extent that EPs are providing services
which get paid under or based on the MPFS, those services are eligible for PQRS negative payment
adjustments. Individual EPs, EPs in PQRS group practices, Accountable Care Organizations (ACOs)
reporting PQRS via the GPRO Web Interface, and Comprehensive Primary Care (CPC) practice sites are
eligible to participate in PQRS. View the complete “2016 PQRS List of Eligible Professionals” (identified
on claims by their individual National Provider Identifier [NPI] and Tax Identification Number [TIN]
combination) on the PQRS How To Get Started webpage.
EPs or PQRS group practices, using their individual rendering NPI or TIN respectively, may report the
quality clinical action for measures within PQRS. Individual EPs report data to CMS at the TIN/NPI level,
while PQRS group practices report data to CMS at the TIN level. Most services payable under fee
schedules or methodologies other than the MPFS are not included in 2016 PQRS (for example, services
provided under federally qualified health center (FQHC) or rural health clinic (RHC) methodologies,
portable X-ray suppliers, independent laboratories including place-of-service code “81,” hospitals, skilled
nursing facilities (SNF), ambulance providers, and ambulatory surgery center facilities). Suppliers of
durable medical equipment (DME) are not eligible to report measures via PQRS since DME is not paid
under the MPFS.
Why should I participate in PQRS?


Help improve health care quality. Driving quality improvement is a core function of CMS. The
vision for the CMS Quality Strategy is to optimize health outcomes by leading clinical quality
improvement and health system transformation. PQRS plays a crucial role to facilitate physician
participation in this process committed to quality improvement.



Be a satisfactory reporter and avoid the 2018 PQRS negative payment adjustment.
Additional information on how to avoid the PQRS negative payment adjustment can be found in
this guide and supporting documentation on the CMS PQRS website.

What are quality measures?
Quality measures are indicators of the quality of care provided by physicians. They are tools that help
CMS measure or quantify health care processes, outcomes, patient perceptions, and organizational
structure and/or systems that are associated with the ability to provide high-quality health care and/or that
relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient­
centered, equitable, and timely care. Refer to page 7 for more information on quality measures.
It is important to review and understand each measure specification especially as it pertains to a specific
reporting mechanism. The measure specification specific to the reporting mechanism will provide
definitions and specific instructions for satisfactorily reporting the measure. This guide provides a web
address under each reporting mechanism for easy location of the measures specifications. Refer to the
next section, “PQRS Measure Selection Considerations” for more information about denominators and
numerators. Also refer to Appendix A: Glossary of Terms, which further defines the terms denominator
and numerator as well as other terms commonly used in PQRS.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 4 of 39

Disclaimer: If reporting for PQRS through another CMS program (such as the Medicare
Shared Savings Program, Comprehensive Primary Care Initiative, Pioneer Accountable Care
Organizations, or other quality reporting program or initiative), please check the program’s
requirements for information on how to report quality data to avoid the PQRS negative
payment adjustment. Please note, although CMS has attempted to align or adopt similar
reporting requirements across programs, EPs should look to the respective quality program to
ensure they satisfy the PQRS, EHR Incentive Program, Value-Based Payment Modifier
(Value Modifier), etc. requirements of each of these programs.

CPT copyright 2015 American Medical Association. All rights reserved. Fee schedules, relati ve value units, conversion factors
and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their
use. The AMA doesnot directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data
contained or not contained herein. CPT is a registered trademark of the American Medical Association.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 5 of 39

PQRS Measure Selection Considerations

The 2016 PQRS measures address various aspects of care, such as prevention, chronic- and acute-care
management, procedure-related care, resource utilization, and care coordination. EPs and PQRS group
practices are not required to report on all of the PQRS measures and must select which measures they
would like to report.
How should I determine which measures to report?
Step

Description
Review the “2016 Physician Quality Reporting System (PQRS) Measures
List” and the PQRS Web-Based Measure Search Tool, available on the PQRS
Measures Codes webpage, to determine which measures, associated domains,
and reporting mechanism(s) may be of interest and applicable to the individual
EP or group practice participating in PQRS via GPRO.


Step 1: Review
the Measures List





Step 2: Consider
important factors

Consider the following factors when selecting measures for reporting:
 Clinical conditions usually treated.
 Types of care typically provided – e.g., preventive, chronic, acute.




Step 3: Review
specifications

Not all measures are available under each PQRS reporting mechanism.
EPs or PQRS group practices should avoid individual measures that do
not or may infrequently apply to the services they provide to Medicare
patients.
With alignment of quality measures across CMS quality reporting
programs, some measures from the EHR Incentive Program may have
been updated or modified during their National Quality Forum
endorsement process. This may result in different measurement titles,
number versions, or National Quality Strategy (NQS) domains from the
corresponding PQRS specification. Please refer to program specific
documentation for accurate interpretation of measures and reporting
criteria.
The GPRO Web Interface reporting mechanism has set measures, all of
which must be reported.

Settings where care is usually delivered – e.g., office, emergency
department (ED), surgical suite.
Quality improvement goals for 2016.
Other quality reporting programs in use or being considered by the NQS
(see further explanation below).

After making a selection of potential measures, review the specifications for
the selected reporting mechanism for each measure under consideration. Select
those measures that apply to services most frequently provided to Medicare
patients by the EP or PQRS group practice.
 EPs or PQRS group practices should review each measure’s
denominator coding to determine which patients may be eligible for the
selected PQRS measure(s). EPs can report individual measures or
Measures Groups, while PQRS group practices can only report
individual measures or all of the measures within the GPRO Web
Interface, if that mechanism is chosen.
 Group practices must report using an EHR, registry, QCDR, or via the
GPRO Web Interface in order to select their measures.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 6 of 39

The National Quality Strategy (NQS)
In 2016, measures are classified according to the 6 NQS domains based on the NQS’s priorities. PQRS
reporting mechanisms typically require an EP or PQRS group practice to report 9 or more measures
covering at least 3 NQS domains, and cross-cutting measures for EPs with billable face-to-face
encounters for satisfactory reporting or participation to avoid the 2018 PQRS negative payment
adjustment when reporting individual measures.
The Six NQS Domains

Patient Safety

Person and CaregiverCentered Experience and
Outcomes

Communication and
Care Coordination

Effective
Clinical Care

Community/
Population Health

Efficiency and
Cost Reduction

What is a measure?
Measures consist of two major components: denominators and numerators.
PQRS Denominators and Numerators

Each component is defined by specific codes described in the respective measure's specification along
with the reporting instructions and use of modifiers.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 7 of 39

See below for an example of a measurement specification construct:

Measure component #1: Denominator
The first measure component is the denominator, which describes the eligible cases for a measure or the
eligible patient population. Physician Quality Reporting measure denominators are identified by ICD-10­
CM , ICD-10-PCS, CPT Category I, and HCPCS codes, as well as patient demographics (age, gender,
etc.), and place of service (if applicable). For GPRO Web Interface and electronic reporting using an
EHR, other clinical coding sets may be included such as SNOMED, LOINC, or RxNorm.
Measure component #2: Numerator
The second component is the numerator describing the specific clinical action required by the measure
for performance. EPs may use the codes present in the numerator to report the outcome of the action as
indicated by the measure. PQRS measure numerators are quality-data codes (QDCs) consisting of
specified non-payable CPT Category II codes and/or temporary G-codes. For GPRO Web Interface and
electronic reporting using an EHR, other clinical coding sets may be included such as SNOMED, LOINC,
or RxNorm in order to capture a specific quality action, test, or value.
How is a measure calculated?
Calculating the PQRS reporting rate (dividing the number of reported numerator outcomes by
denominator-eligible encounters) identifies the percentage of a defined patient population that was
reported for the measure.
For performance rate calculations, some patients may be subtracted from the denominator based on
medical, patient, or system performance exclusions/exceptions (depending upon reporting mechanism)
allowed by the measure.
The final performance rate calculation represents the eligible population that received a particular process
of care or achieved a particular outcome (measure defined performance met outcome). It is important to
review and understand each measure's specification, as it contains definitions and specific instructions for
reporting the measure.
How do I report PQRS measures?
PQRS offers several reporting mechanisms for reporting measures. There may be different mechanisms
available within the specific reporting mechanism to satisfactorily report to avoid the 2018 negative
payment adjustment. Refer to Appendix B: Decision Trees – 2016 PQRS Reporting/Participation for
Avoiding the 2018 PQRS Negative Payment Adjustment for the Decision Trees designed to help
participants select among the multiple reporting mechanisms available in PQRS. EPs and PQRS group
Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 8 of 39

practices should consider which reporting mechanism best fits their practice and should choose
measures within the same option of reporting.
 Please note that PQRS defines a group practice as a single TIN with 2 or more individual EPs (as
identified by individual NPI) that have reassigned their billing rights to the TIN.
Determining Group Size
A group practice must have 2 or more EPs who have reassigned their billing rights to the TIN in order to
participate via PQRS GPRO. The group practice will determine its size based on the number of EPs
billing under the TIN at the time of registration. During registration, group size will be categorized as 2-24
EPs, 25-99 EPs and 100 or more EPs. The group practice will need to indicate their group size to CMS by
selecting one of these size categories. Reporting requirements and available reporting mechanisms may
vary based on the group size. Once a group practice (TIN) registers to participate in the GPRO, this is the
only PQRS reporting method available to the group and all individual NPIs who bill Medicare under the
group’s TIN for 2016.
 Please note that an individual EP who is a member of a group practice participating in PQRS
GPRO is not eligible to separately report under PQRS as an individual EP under that same TIN
(that is, for the same TIN/NPI combination).
Reporting Mechanisms Available for 2016
Individual EPs






EHR direct product that is Certified
Electronic Health Record Technology
(CEHRT)
EHR data submission vendor (DSV) that
is CEHRT
Qualified PQRS registry
Qualified Clinical Data Registry (QCDR)
Medicare Part B claims submitted to CMS

PQRS Group Practices









EHR direct product that is CEHRT (2+

providers)

EHR DSV that is CEHRT (2+ providers)

Qualified PQRS registry (2+ providers)

QCDR (2+ providers)

GPRO Web Interface (25+ providers)

CAHPS for PQRS using CMS-certified

survey vendor (2+ providers) (CAHPS is

supplemental to other reporting

mechanisms) (required for groups of 100+

providers)

PQRS group practices must register for
the GPRO and select their reporting
mechanism by June 30, 2016. For more
information about reporting PQRS
measures as a group, visit the PQRS
How to Get Started webpage.

Note: As outlined in the 2016 MPFS final rule, all PQRS quality measure data collected from individual
EPs and PQRS group practices via all reporting mechanisms are available for public reporting. In
addition, all individual and group-level QCDR measures and CAHPS for PQRS summary survey
measures are available for public reporting. All data that meet the public reporting standards will be
published on Physician Compare in late 2017. For more information on public reporting, view the CMS
Physician Compare Initiative website.
Analysis of PQRS Data: Reporting Frequency and Performance Timeframes
Reporting frequency and performance timeframes are considerations for satisfactorily reporting through
the various PQRS reporting mechanisms.
Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 9 of 39

What is “reporting frequency”?
Each measure specification includes a reporting frequency for each denominator-eligible patient (see
section on Measure Selection Considerations) seen during the reporting period. The reporting
frequency described in the measure specification’s instructions applies to each individual EP and PQRS
group practice submitting individual PQRS measures. The reporting frequency is used in analyzing each
measure to help determine satisfactory reporting, according to the reporting frequency in the
“Instructions” section of the measure:

What is a performance timeframe?
A measure’s performance timeframe is defined in the measure’s description and is distinct from the
reporting frequency requirement defined in the measure’s instructions. The performance timeframe,
unique to each measure, outlines the timeframe in which the clinical action described in the numerator
may be completed. See Appendix A: Glossary of Terms.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 10 of 39

Satisfactorily Report Measures

PQRS EPs and PQRS group practices can refer to the following educational resources, available in 2016:


“2016 Physician Quality Reporting System (PQRS) Electronic Health Record (EHR) Reporting
Made Simple” available on the PQRS Electronic Reporting Using an EHR webpage



“2016 Physician Quality Reporting System (PQRS) Measures – Registry Reporting Made Simple”
available on the PQRS Registry Reporting webpage



“2016 Physician Quality Reporting System (PQRS) Qualified Clinical Data Registry (QCDR)
Participation Made Simple” available on the PQRS Qualified Clinical Data Registry Reporting
webpage



“2016 Physician Quality Reporting System (PQRS) Measures – Claims Reporting Made Simple”
available on the PQRS Measures Codes webpage



“2016 Physician Quality Reporting System (PQRS) Group Practice Reporting Option (GPRO)
Web Interface Reporting Made Simple” available on the PQRS GPRO Web Interface webpage



“2016 CMS-Certified Survey Vendor Made Simple” available on the PQRS CMS-Certified Survey
Vendor webpage



“2016 Physician Quality Reporting System (PQRS) Getting Started with Measures Groups”
available on the PQRS Measures Codes webpage

What’s the difference between “satisfactory reporting” vs. “satisfactory participation?”
“Satisfactory reporting” refers to participating in 2016 PQRS to avoid the 2018 negative payment
adjustment while “satisfactory participation” refers to EPs participating in the “qualified clinical data
registry (QCDR)” reporting mechanism.
What are the components of a measure?
Please refer to page 7 for more information on measure components.
How should I select which reporting mechanism to use?
Refer to Appendix B: Decision Trees – 2016 PQRS Reporting/Participation for Avoiding the 2018
PQRS Negative Payment Adjustment for the Decision Trees designed to help participants select among
the multiple reporting mechanisms available in PQRS.
Note: For the claims and registry reporting mechanisms, individual EPs and PQRS group practices that
report less than 9 measures or less than 3 NQS domains will be subject to Measure-Applicability
Validation (MAV). For more information on MAV, please see the PQRS Analysis and Payment webpage.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 11 of 39

Appendix A: Glossary of Terms

Terms

Definitions

Base Claim
Diagnosis

PQRS refers to all diagnoses listed (Item 21 of the CMS-1500 claim form, field 66 of
the CMS-1450 form) associated with physician office, outpatient, and inpatient visits
for reporting.

CMS-1450 Form

The CMS-1450 form (UB-04 at present) can be used by an institutional provider to bill
a Medicare fiscal intermediary when a provider qualifies for a waiver from the
Administrative Simplification Compliance Act requirement for electronic submission of
claims. It is also used for billing of institutional charges to most Medicaid State
Agencies. Please contact your Medicaid State Agency for more details on their
requirements for this paper form.
Regardless of the reporting mechanism, CAH II providers will need to continue to add
their NPI to the MCS-1450 claim form for analysis of PQRS reporting at the NPI-level.
Refer to Appendix E for more information.

CMS-1500 Form

Health Insurance Claim Form CMS-1500 is the standard paper claim form to bill
Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. Form
CMS-1500 may be suitable for billing various government and some private insurers.
Refer to Appendix D for more information.

CMS-Certified
Survey Vendor

A CMS-certified survey vendor is a reporting mechanism for purposes of reporting
CAHPS for PQRS surveys for PQRS group practices. The CMS-certified survey
vendor is required to be certified for a particular program year by CMS in order to
submit the CAHPS for PQRS survey data.

Claim

For PQRS purposes, one or more claims will be reconnected based on TIN, NPI,
beneficiary, and date of service.

Claim
Adjustment
Reason Code
(CARC)

Claim adjustment reason codes (CARC) communicate an adjustment, meaning that
they must communicate why a claim or service line was paid differently than it was
billed. If there is no adjustment to a claim/line, then there is no adjustment reason
code.

CPT Category II
Codes or CPT II
codes

A set of supplemental CPT codes intended to be used for performance measurement.
These codes may be used to facilitate data collection about the quality of care
rendered by coding certain services, test results or clinical actions that support
nationally established performance measures and that the evidence has
demonstrated to contribute to quality patient care.2
For PQRS, CPT Category II codes are used to report quality measures on a claim for
measurement calculation.
CPT Category II or CPT II codes were developed through the CPT Editorial Panel for
use in performance measurement, encode the clinical action(s) described in a
measure’s numerator. CPT II codes consist of five alphanumeric characters in a s tring
ending with the letter “F.” CPT II codes are not modified or updated during the
reporting period and remain valid for the entire program year as published in the
measure specifications manuals and related documents for PQRS.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 12 of 39

Terms

Definitions

Denominator
(Eligible Cases)

The lower portion of a fraction used to calculate a rate, proportion, or ratio.

Denominator
Exception

The definition included there is 'Those conditions that should remove a patient,
procedure, or unit of measurement from the denominator of the performance rate only
if the numerator criteria are not met. Denominator exceptions allow for adjustment of
the calculated score for those providers with higher risk populations. Denominator
exceptions are used only in proportion measures. Denominator exceptions allow for
the exercise of clinical judgment and should be specifically defined where capturing
the information in a structured manner fits the clinical workflow.

The denominator must describe the population eligible (or episodes of care) to be
evaluated by the measure. This should indicate age, condition, setting, and timeframe
(when applicable). For example, “Patients aged 18 through 75 years with a diagnosis
of diabetes.” PQRS measure denominators are identified by ICD-10-CM, CPT
Category I, and HCPCS codes, as well as patient demographics (age, gender,
etc.), and place of service (if applicable).

These cases are removed from the denominator; however the number of patients with
valid exceptions may still be reported. Exceptions allow for the exercise of clinical
judgment. Allowable reasons fall into three general categories:



Denominator
Exclusion

Medical reasons
Patient reasons
System reasons

Patients with conditions who should be removed from the measure population and
denominator before determining if numerator criteria are met.
Patients who should be removed from the measure population and denominator
before determining if numerator criteria are met. Denominator exclusions are used in
proportion and ratio measures to help narrow the denominator. For example, patients
with bilateral lower extremity amputations would be listed as a denominator exclusion
for a measure requiring foot exams.

Denominator
Statement

A statement that describes the population eligible for the performance measure. For
example, “Patients aged 18 through 75 years with a diagnosis of diabetes.”

Diagnosis
Pointer

Item 24E of the CMS-1500 claim form or electronic equivalent. For PQRS, the line
item containing the quality-data code (QDC) for the measure should point to one
diagnosis (from Item 21) per measure-specific denominator coding.
To report a QDC for a measure that requires reporting of multiple diagnoses, enter
the reference number in the diagnosis pointer field that corresponds to one of the
measure’s diagnoses listed on the base claim. Regardless of the reference number in
the diagnosis pointer field, both primary and all secondary diagnoses are considered
in PQRS analysis.

Electronic
Health Record
(EHR)

The Electronic Health Record (EHR) is a longitudinal electronic record of patient
health information generated by one or more encounters in any care delivery setting.
Included in this information are patient demographics, progress notes, problems,
medications, vital signs, past medical history, immunizations, laboratory data and
radiology reports. The EHR automates and streamlines the clinician's workflow. The
EHR has the ability to generate a complete record of a clinical patient encounter ­ as
well as supporting other care-related activities directly or indirectly via interface ­
including evidence-based decision support, quality management, and outcomes
reporting.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 13 of 39

Terms

Definitions

Eligible
Professional
(EP)

Refer to the PQRS How to Get Started webpage for the “2016 PQRS List of Eligible
Professionals”
Some professionals may be eligible to participate per their specialty, but due to billing
method may not be able to participate:
 Professionals who do not bill Medicare at an individual National Provider
Identifier (NPI) level, where the rendering provider’s individual NPI is entered
on CMS-1500 or CMS-1450 type paper or electronic claims billing, associated
with specific line-item services.
Services payable under fee schedules or methodologies other than the MPFS are not
included in PQRS.
Please note: EPs who render denominator-eligible services under Medicare Part B
PFS via CMS-1500 or CMS-1450 claim are able to participate in PQRS regardless of
the organization’s participation in other fee schedules or methodologies. For example,
an EP who bills under an organization that is registered as a federally qualified health
center (FQHC), yet (s)he renders services that are not covered by the FQHC
methodology.

Encounter

Encounters with patients during the reporting period which include: CPT Category I
E/M service codes, CPT Category I procedure codes, or HCPCS codes found in a
PQRS measure’s denominator. These codes count as eligible to meet a measure’s
inclusion requirements when occurring during the reporting period.

G-codes for
PQRS

A set of CMS-defined temporary HCPCS codes used to report quality measures on a
claim. G-codes are maintained by CMS.

Group Practice
Reporting
Option (GPRO)

The Group Practice Reporting Option (GPRO) was introduced in 2010 as a reporting
mechanism for group practices to participate in PQRS. PQRS defines a group
practice as a single TIN with 2 or more individual EPs (as identified by Individual NPI)
that have reassigned their billing rights to the TIN.

ICD-10-CM
Diagnosis
Codes

ICD-10-CM is a clinical modification of the World Health Organization’s ICD-10, which
consists of a diagnostics classification system. ICD-10-CM includes the level of detail
needed for morbidity classification and diagnostics specificity in the United States.9
For more information on ICD-10 implementation, visit the CMS ICD-10 Website:
http://www.cms.gov/Medicare/Coding/ICD10/index.html.

Line-Item
Diagnosis

Six service lines are in Section 24 of the CMS-1500 claim form to accommodate
submission of the rendering NPI and supplemental information to support the billed
service, including the pointed diagnosis from Item 21.
QDCs are submitted on the line item in section 24 for PQRS.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 14 of 39

Terms

Definitions

Measure





Measure
Reporting
Frequency







Performance Measure


A quantitative tool (e.g., rate, ratio, index, percentage) that provides an
indication of performance in relation to a specified process or outcome.



See also process measure and outcome measure.1,6

Measure Types


Outcome measure: A measure that assesses the results of healthcare that
are experienced by patients: clinical events, recovery and health status,
experiences in the health system, and efficiency/cost.6



Process measure: A measure that focuses on steps that should be followed
to provide good care. There should be a scientific basis for believing that the
process, when executed well, will increase the probability of achieving a
desired outcome. 6



Structural measure: A measure that assesses features of a healthcare
organization or clinician relevant to its capacity to provide healthcare.6

Patient-Process: Report a minimum of once per reporting period per individual
EP (NPI).



If the measure is reported more than once during the reporting period,
performance rates are calculated using the most advantageous QDC
submitted.



Reflect quality actions performed throughout the reporting period or other
timeframe.

Patient-Intermediate: Report a minimum of once per reporting period per
individual EP (NPI).



If the measure is reported more than once during the reporting period,
performance rates are calculated using the most recent QDC submitted.



Often reflects lab or other test value, so the most recent measurement is
desired.

Patient-Periodic: Report once per timeframe specified in the measure for each
individual EP (NPI) during the reporting period.




Examples include once per month and three times per year.

Episode: Report once for each occurrence of a particular illness/condition by
each individual EP (NPI) during the reporting period.



Usually reflects a clinical episode, difficult to determine from a single Part B
claim.



Requires specialized analytics to determine the episode.



Procedure: Report each time a procedure is performed by the individual EP
(NPI) during the reporting period.



Visit: Report each time the patient is seen by the individual EP (NPI)

during the reporting period.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 15 of 39

Terms

Definitions

NPI

National Provider Identifier of the individual EP billing under the Tax ID (“NPI within
the Tax ID”).

Performance
Numerator

The upper portion of a fraction used to calculate a rate, proportion, or ratio.

Numerator
Statement

A statement that describes the clinical action that satisfies the conditions of the
performance measure.

The numerator must detail the quality clinical action expected that satisfies the
condition(s) and is the focus of the measurement for each patient, procedure, or other
unit of measurement established by the denominator (that is, patients who received a
particular service or providers that completed a specific outcome/process)..

For example, “Patients that were assessed for the presence or absence of urinary
incontinence.”
Performance
Timeframe

A designated timeframe within which the action described in a performance measure
should be completed. This timeframe is generally included in the measure description
and may or may not coincide with the measure’s data reporting frequency
requirement.

Performance
Measure
Exclusion
Modifiers

Modifiers developed exclusively for use with CPT Category II codes to indicate
documented medical (1P), patient (2P), or system (3P) reasons for excluding patients
from a measure’s denominator. 2

Performance
Measure
Reporting
Modifier 8P

The 8P reporting modifier is intended to be used as a “reporting modifier” to allow the
reporting of circumstances when an action described in a measure’s numerator is not
performed and the reason is not otherwise specified.

Place of Service

References Place of Service Codes (POS) from the list provided in section 10.5 of the
“Medicare Claims Processing Manual”.

Qualified
Clinical Data
Registry (QCDR)

A CMS-approved entity (such as a registry, certification board, collaborative, etc.) that
collects medical and/or clinical data for the purpose of patient and disease tracking to
foster improvement in the quality of care furnished to patients.

Quality-Data
Code (QDC)

Specified CPT Category II codes with or without modifiers and G-codes used for
submission of PQRS data via claims-based or registry reporting mechanisms. The
“2016 Physician Quality Reporting System (PQRS) Individual Measure Specifications
for Claims and Registry” contains all codes associated with each PQRS measure and
instructions for data submission.

8P performance measure reporting modifier - action not performed, reason not
otherwise specified 2

QDCs are non-payable Healthcare Common Procedure Coding System (HCPCS)
codes composed of specified CPT Category II codes and/or G-codes that describe
the clinical action required by a measure’s numerator. Clinical actions can apply to
more than one condition and, therefore, can also apply to more than one measure.
For PQRS, where necessary, to avoid shared CPT Category II codes, G-codes are
used to distinguish clinical actions across measures. Some measures require more
than one clinical action and may have more than one CPT Category II code, G-code,
or a combination associated with them. EPs should review numerator reporting
instructions for each measure carefully.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 16 of 39

Terms

Definitions

Qualified
Registry

An entity that collects clinical data from an EP or group practice and submits it to
CMS on behalf of the EP or group practice.

Rationale

A brief statement describing the evidence base and/or intent for the measure that
serves to guide interpretation of results. 4

Remittance
Advice (RA)

Means utilized by Medicare contractors to communicate to providers, submitting
measures through the claims-based reporting mechanism, of processing decisions
such as payments, adjustments, and denials.7

Remittance
Advice Remark
Codes (RARC)

Remittance Advice Remark Codes (RARCs) are used to provide additional
explanation for an adjustment already described by a Claim Adjustment Reason Code
(CARC) or to convey information about remittance processing. Each RARC identifies
a specific message as shown in the Remittance Advice Remark Code List. There are
two types of RARCs, supplemental and informational. The majority of the RARCs are
supplemental; these are generally referred to as RARCs without further distinction.
Supplemental RARCs provide additional explanation for an adjustment already
described by a CARC. The second type of RARC is informational; these RARCs are
all prefaced with Alert: and are often referred to as Alerts. Alerts are used to convey
information about remittance processing and are never related to a specific
adjustment or CARC.

Reporting
Frequency

The number of times quality-data codes (QDCs) specified for a quality measure must
be submitted on claims during the reporting period. The reporting frequency for each
measure is described in the “2016 Physician Quality Reporting System (PQRS)
Individual Measure Specifications for Claims and Registry” posted on the CMS Web
site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment­
Instruments/PQRS/MeasuresCodes.html

Reporting
Mechanisms

2016 reporting mechanisms available for avoiding the payment adjustment: claimsbased; registry-based; electronic health record (EHR); participation via QCDR;
CAHPS for PQRS, or group practice reporting option (GPRO) Web Interface. Refer to
Appendix B: “Decision Trees – 2016 PQRS Reporting/Participation for Avoiding
the 2018 Negative Payment Adjustment”.

Reporting
Period

The period during which PQRS measures are to be reported for covered professional
services provided.
A 12-month (January 1, 2016 through December 31, 2016) time period is available for
the 2016 reporting mechanism the EP selects for submitting PQRS quality data.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 17 of 39

Sources

1. Agency for Health Care Research & Quality (AHRQ) National Quality Measures Clearinghouse
Glossary

2. IBID, PSNet, Patient Safety Network Glossary
3. American Medical Association (AMA), CPT® Category II Index of Alphabetic Clinical Topics
4. Institute of Medicine (IOM), Performance Measurement Accelerating Improvement, Appendix A
Glossary, National Academies Press

5. Joint Commission on Accreditation of Health Care Organizations (JCAHO)
6. CMS Blueprint for the CMS Measures Management System, Version 11, July 2014
7. QualityNet, QMIS Specification Manual for National Hospital Quality Measures, Appendix D-3,
Glossary of Terms version 2.3b, 9-28-2007

8. CMS Medicare Learning Network, Understanding the Remittance Advice: A Guide for Medicare
Providers, Physicians, Suppliers, and Billers

9. Medicare Claims Processing Manual: Chapter 26 – Completing and Processing Form CMS – 1500
Data Set

10. American Health Information Management Association (AHIMA), Understanding ICD-10, retrieved
from official AHIMA website

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 18 of 39

Appendix B: Decision Trees - 2016 PQRS Reporting/Participation for

Avoiding the 2018 Negative Payment Adjustment
The individual EP or PQRS group practice will need to determine the best reporting mechanism for
participation. PQRS group practices will select their reporting mechanism during registration and the
group will need to meet the reporting requirements for the group size selected regardless of changes to
the group size after registration. Following are the different reporting mechanisms available for
participation in 2016 PQRS as an individual EP or as a PQRS group practice.

Version 1.0
CPT only copy right 2015 American Medical Association. All rights reserv ed.

2/18/2016

Page 19 of 39

I WANT TO PARTICIPATE IN 2016 PQRS
TO AVOID THE 2018 NEGATLVE PAYMENT ADJUSTMENT
SELECT REPORTIN"G MECHANJSM
(R
p!JICIICcllol 2-99 £9'.s
A~90 tor PQRS 9"1l1P

~,o1100-,.EPf

i-

QUAI.IRfO ltfGtSTRYJtl;PQR'flNO FOR
GROUP PR.ACllCeS

OUAl.lMO R! GtSTR'f AUO,tTl!iG

10ft GROI.IP PftACTlCl.tl .. CEttTIFl!O
,uRYEY YlNOOR

aF c 9 MEASURES OR c 3 NOS
OOMAIN'S APPLY,

H.we all CAHPS lot PQRS &umma,y
IF it 9 MEASURES ACROSS 3

!ilA'&'y ine86ure6 ( 12) reported on lhe

REPoRT ON 1--8 INOIVIOUAL

NOS DOMAINS APPLY. REPORT

grauJf9 beh8lt YI& a CMS.cer111!ed Suf"tlt!)'

t.EASURES. COVERING

COVERJNG 3 OR MORE NQS
DOMAINS AS A GROUP

APPI.ICA8t.E OOMAINS, AS A
GROUP
CAHPS for PORS !IAf+As !he PORS
cron-aAllng meast.t'e ~remEinL

PQRSgrouppr.,d~eadonal:nced
lo AIPQl't

•n ,J,d(l!ijQnill
......,,. ~ n g
AND

~ el!ICh mcasin to, n1 lea,,1

50% ol •ppllcl:,ble Modialre ?tlrt B
PF$ pa()ents

a°"~

M$sswtts .-ir/1
tat~ wlll not be OOINlted.

11MOHTHS

111116 • 12/3tl1(1

If 111 moa..utH are , a11,t1ctof1I)'
repot1od, It!• M11aur1pllco!ill Modic:n1e Pnrl 8
PFS~tionts
Me;Ml,I,'$• wjlfl a 0 % ~
rate ~ not De COUl'lrsd'.

°'°"Pt~ on les51Nll"I 6 tr1Na1rn
o, le&& ltla11 2 OOl'Nlns \WI be ll.lbfeel to
A:~iy Measure-Appllcebfily ValidatJon
(MAV)
CAHPS II»' PQRS fulfills the PORS ~
OJtslng ll'IN$tlf9 r9qulr11mcm1 PORS grwp

pracilce& do no1 neea 10 reporl an
8Cldi41onal ci'OSS-CUl1ing m&aSUf&.

12MOHTHS

V1 t l6 • 12131116

Mall: A9ICll,,CI pra~ ~ IO unlae ._

OPDCWI mull 11,dc:;11• !If lmlll'C 10 n.wt N
c;AHPS to, PQR$~ ~ v,nen
~ 10 l*"llcplllle l'I th• POR$wi~O
12MONntS

1/1r,G -12f3H16

2/18/2016

Page 25 of 39

I WANT TO PARTICIPATE IN 2016 PQRS
TO AVOID THE 2018 NEGATIVE PAYMENT ADJUSTMENT
SELECT REPORTING MECHANISM
(Refer ro the 2016 Phyele1an Quallty Repoc11fl9 Systen1 ~'8a$tl(e$ l.l$t .for a N-Sl;ng ol a# 2016 mea-Wl'fs snt1CifJC.JVOt1s lor tlitJ scloctld lepOrf/ng n1~j&m($) tor 2016 PORSJ

OW UFlEO CllNICAl

ELECTRONIC

a.AIMS..a.\St: 0

IW'Ofll1NG

REPORTING

USING AN EHR

•

DA.TA RfGISlRV
REPORTING

GROUP PRACTICE REPORTING Of'TION TO AVOID 2018
PORS NEGATIVE PAYMENT 4QJUSTMENT
HIMll ~ S giNNp ,nc:llnit Of 100 9t moi• fP• _.t11i,.ilr•d 110 •11ptW1
CiUil'S tor PORS

I

I
CAHPS lcw POflS

PORS (ll'Ou1>1l'aetleetol
2-e'l EP1

D!RtCT tHR PAOOUC:T THATtS
C.0 1)1sc::oic. ~ 11mo IO um,111 lt'4 Ol*)l'I mu111 lnRQ

T'2 MONTI+ EP&

QUALIFIED CLINICAL DAfA
REG;ISTRY REPORTING FOR
GROUP PRACnt£S

I

QUALIFIED CLINICAL DATA

REGISTRY REPORTRtG FOfl GROUP
PRACTICES• CERflF'.IED SURVEY

VENOOR
.t 9 MEASUAl:S ACROSS 3
NOS DOMAINS APPLY

REPORT ON 2: 9 INOfVIOUAL MEASURES
COVERING 3 NOS OOMAJNS AND

REPORT > 50% OF THE GROUP PRACTICE'S
PATIENTS

0 1t.hc&e me~sum. 1ef)()tl on at 1eais1 2 outcome
measures.. If 2 outcome measures are not avalable,
repo,1 Qn at ieas:t I outcome measure and al least 1

of the tollOwlnO type$ QI r'l'IC3$Uf C$ - l'CSOUtCI) U$0.
patlenl experience of care, e.fficiency/approprlate

u$0. 0t ~uent so1ety,
12MONTHS

111116 • 12131/ 16
PQRS 9fQVP p,sczlces p8rrlcipatlng viQ qlJ8111/fJCJ
ctJnlCttl dtltt, roglstry 010 not h rod lo PORS

Have all CAHPS for PORS summary
survey me-asures ( 12) reported on the
group's beh;,11 via a Cr,.t$.,()8,r'1.,fled SUt'VCY
vFile Typeapplication/pdfFile Title2016 Physician Quality Reporting System (PQRS) Implementation GuideSubject2016 PQRS Implementation GuideAuthorCenters for Medicare & Medicaid Services (CMS)File Modified2016-02-18File Created2016-02-18